Provider Demographics
NPI:1447210489
Name:GREEN, KEVIN O'SHEA SR (PTA, MLDT)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:O'SHEA
Last Name:GREEN
Suffix:SR
Gender:M
Credentials:PTA, MLDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 BAYNARD RD
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29906-6777
Mailing Address - Country:US
Mailing Address - Phone:843-597-0993
Mailing Address - Fax:
Practice Address - Street 1:1076 RIBAUT RD
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-5490
Practice Address - Country:US
Practice Address - Phone:832-521-1970
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC948225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant